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Prosthetic Surgical Tissue Valve Fracturing Using A High-pressure Balloon To Facilitate Transcatheter Valve-in-valve Implantation
Keith Allen1, Adnan Chhatriwalla1, David Cohen1, John Saxon1, Sanjeev Aggarwal1, Anthony Hart1, Suzanne Baron1, Anthony Bavry2, Thomas Beaver2, Ashkan Karimi2, Michael Lim3, Richard Lee3, Joshua Rovin4, A. Michael Borkon1.
1St. Luke's Mid America Heart Institute, Kansas City, MO, USA, 2University of Florida, Gainsville, FL, USA, 3Saint Louis University, St. Louis, MO, USA, 4Morton Plant Hospital, Tampa Bay, FL, USA.
OBJECTIVE: Valve-in-valve transcatheter aortic valve replacement (ViV TAVR) may be suboptimal in small prosthetic surgical valves and result in unfavorable post implant gradients. We previously reported bench top testing demonstrating the feasibility of bioprosthetic ring fracture of some surgical tissue valves using a high-pressure balloon (STS, Jan 2017; https://youtu.be/KTkQAaES6IA). A multi-center clinical experience with this technique is reported here.
METHODS: Prosthetic surgical tissue valve enlargement using a high-pressure balloon (fracturing the ring) was performed in 12 patients at six US centers in order to facilitate ViV TAVR. Procedural variables including hemodynamic gradients and post-operative complications are reported here.
RESULTS: Heart Team evaluation deemed patients at high risk (9) or inoperable (3) for redo surgical aortic valve replacement. Surgical valves treated included Magna (4), Mitroflow (5), Mosaic (2) and Trifecta (1) with valve sizes of 19mm (4), 21mm (4), 23mm (3) and 25mm (1) using both self-expanding (9) and balloon expandable (3) transcatheter aortic valves. Access for ViV TAVR was transfemoral (11) and transcarotid (1). Surgical valves were fractured with either a Bard TRU (11) or Bard Atlas Gold (1) high pressure balloon that was 1mm larger than the surgical valve size. Surgical valve fracture was performed before TAVR in 2 patients and after ViV TAVR in 10 patients. Preoperative prosthetic valve gradient in patients treated for AS was mean 53mm Hg (range 36-80). Following ViV TAVR a residual mean gradient of 24mm Hg (range 12-50) was reduced to a mean gradient of 5mm Hg (range 3-9) following surgical valve fracture. There were no intraoperative or postoperative complications with median LOS of 3 days (1-7). Representative valve fracture is demonstrated fluoroscopically (Fig A) and by CT (Fig B). 
CONCLUSIONS: Residual gradients following ViV TAVR can be safely reduced by fracturing the sewing ring of some surgical valves with a high-pressure balloon. Optimal transcatheter valve expansion using this technique can optimize hemodynamics and may positively impact long term TAVR durability and improve patient outcomes and warrants further investigation.
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